CSPR - CERTIFIED SPECIALIST PAYMENT

CSPR - CERTIFIED SPECIALIST PAYMENT

REP (HFMA) QUESTIONS AND ANSWERS

Question :Steps used to control costs of managed care

include:

Bundled codesCapitation Payer and Provider to agree on reasonable payment

Correct Answer:Bundled codesCapitation Payer and

Provider to agree on reasonable payment

Question :DRG is used to classify

Inpatient admissions for the purpose of reimbursing hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual costs incurred

Correct Answer:Inpatient admissions for the purpose of

reimbursing hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual costs incurred

Question :Identify the various types of private health plan

coverage HMOConventionalPPO and POSHDHP/SO plans - high- deductible health plans with a savings option; Private - Include higher patient out-of-pocket expenditures for treatments that can serve to reduce utilization/costs.

Correct Answer:HMOConventionalPPO and

POSHDHP/SO plans - high-deductible health plans with a

savings option; Private - Include higher patient out-of-pocket expenditures for treatments that can serve to reduce utilization/costs.

Question :Managed care organizations (MCO) exist primarily

in four forms:

Health Maintenance Organizations (HMO)Preferred Provider Organizations (PPO)Point of Service (POS) OrganizationsExclusive Provider Organizations (EPO)

Correct Answer:Health Maintenance Organizations

(HMO)Preferred Provider Organizations (PPO)Point of Service (POS) OrganizationsExclusive Provider Organizations (EPO)

Question :Identify the various types of government‐

sponsored health coverage:

Medicare - Government; Beneficiaries enrolled in such plans, but, participation in theseplans is voluntary.MedicaidMedicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a managed care plan.Medicare Managed Care (a.k.a. Medicare Advantage Plans)

Correct Answer:Medicare - Government; Beneficiaries

enrolled in such plans, but, participation in theseplans is voluntary.MedicaidMedicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a managed

care plan.Medicare Managed Care (a.k.a. Medicare Advantage Plans)

Question :Identify some key drivers of increasing healthcare

costs DemographicsChronic ConditionsProvider payment systems

• Provider payment systems that are designed to reward

volume rather than quality, outcomes, and preventionConsumer PerceptionsHealth Plan pressurePhysician RelationshipsSupply Chain

Correct Answer:DemographicsChronic ConditionsProvider

payment systems - Provider payment systems that are designed to reward volume rather than quality, outcomes, and preventionConsumer PerceptionsHealth Plan pressurePhysician RelationshipsSupply Chain

Question :Health Maintenance Organizations (HMO)

ReferralsPCPPatients must use an in-network provider for their services to be covered.Reimbursement - majority of services offered are reimbursed through capitation payments

(PMPM)

Correct Answer:ReferralsPCPPatients must use an in-

network provider for their services to be covered.Reimbursement - majority of services offered are reimbursed through capitation payments (PMPM)

Question :Medicare is composed of four parts: Part A - provides inpatient/hospital, hospice, and skilled nursing coveragePart B - provides outpatient/medical coveragePart C - an alternative way to receive your Medicare benefits (known as MedicareAdvantage)Part D - prescription drug coverage

Correct Answer:Part A - provides inpatient/hospital,

hospice, and skilled nursing coveragePart B - provides outpatient/medical coveragePart C - an alternative way to receive your Medicare benefits (known as MedicareAdvantage)Part D - prescription drug coverage

Question :HMO Act of 1973

The HMO Act of 1973 gave federally qualified HMOs the right to mandate that employers offer their product to their employees under certain conditions. Mandating an employer meant that employers who had 25 or more employees and were for‐profit companies were required to make a dual choice available to their employees.

Correct Answer:The HMO Act of 1973 gave federally

qualified HMOs the right to mandate that employers offer their product to their employees under certain conditions.Mandating an employer meant that employers who had 25 or more employees and were for‐profit companies were required to make a dual choice available to their employees.